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NEW CLIENT INTAKE

First Name *

Last Name *

Date of birth *

Birth Place - City, State, Country *

Birth Time

Email *

Phone *

Address *

City *

State *

Postal code *

Country

Country

Emergency Contact *

Emergency Contact Phone *

Relationship

Spouse / Partner

Parent

Friend

Other

Are you currently receiving psychological services, professional counseling, psychiatric services, and/or any other mental health services?

*

Yes

No

Are you currently taking any psychiatric prescription medication?

*

Yes

No

If so, what medications are you taking?
Please list dosages and frequency.

Have you been psychiatrically hospitalized in the past? *

Yes

No

If yes, please list dates below:

How would you rate your physical health at the present time? *

Poor

Unsatisfactory

Satisfactory

Good

Very good

Do you consume alcohol regularly? *

Yes

No

In one month, how many times do you have four or more drinks in a 24-hour period?

How often do you engage in recreational drug use? *

Daily

Weekly

Monthly

Rarely

Never

What kinds of recreational drugs do you use:

Alcohol

Cannabis

Cocaine

MDMA (Ecstasy/Molly)

LSD

Psilocybin (Mushrooms)

Methamphetamine

Opioids (Heroin, Prescription Painkillers)

Benzodiazepines

Ketamine

Other

Are you currently in a romantic relationship? *

Yes

No

If yes, how long have you been in this relationship?

On a scale from 1-10 (10 being great), how would you rate the quality of your relationship?

In the last year, have you had any major life changes (e.g. new job, moving, illness, relationship change, etc.)?

Do you practice a religion? *

Yes

No

If yes, what is your faith?

Are you currently employed? *

Yes

No

If yes, who is your employer?

What is your position?

Are you happy in your current position?

Yes

No

Does your work make you stressed?

Yes

No

If yes, what are your work-related stressors?

Have you felt depressed recently? *

Yes

No

If yes, for how long?

Have you had any suicidal thoughts recently? *

Yes

No

If yes, how often?

Frequently

Sometimes

Rarely

Have you ever had suicidal thoughts in your past? *

Yes

No

If yes, how long ago?

How often did you have these thoughts?

Frequently

Sometimes

Rarely

The following is to provide information about your family history. Please mark each as yes or no.

Depression *

Yes

No

If yes, please indicate the family member(s) affected.

Suicide *

Yes

No

If yes, please indicate the family member(s)affected.

Bipolar Disorder *

Yes

No

If yes, please indicate the family member(s) affected.

Panic Attacks *

Yes

No

If yes, please indicate the family member(s) affected.

Alcohol/Substance Abuse *

Yes

No

If yes, please indicate the family member(s) affected.

Eating Disorder *

Yes

No

If yes, please indicate the family member(s) affected.

Trauma History *

Yes

No

If yes, please indicate the family member(s) affected.

Domestic Violence *

Yes

No

If yes, please indicate the family member(s) affected.

Sexual Abuse *

Yes

No

If yes, please indicate the family member(s) affected.

Obsessive Compulsive Behavior *

Yes

No

If yes, please indicate the family member(s) affected.

Schizophrenia *

Yes

No

If yes, please indicate the family member(s) affected.

List your strengths and what you like most about yourself: *

List areas you feel you need to develop: *

What are some ways you cope with life obstacles and stress? *

What are your goals for our session(s) what would you like to accomplish? *

What is the amount of time you are willing to commit to your healing? *

Less than 3 months, looking for a quick fix

About 6 months, I know this will take time

12+ months or as long as it takes

If you could snap your fingers and all of your physical, mental, emotional, and spiritual stress could decrease by 70-80%, what would that transformation be work for you? *

Not willing to spend any money

Less than $8,000

$8,000-$16,000

Over $16,000

Sky is the limit, I'll do whatever it takes

NEXT

Listening. Remembering. Becoming.

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DISCLAIMER:

Spiritual Healing is not a substitute for allopathic medicine.
If you have a health concern, you should always consult a physician.
Cassandra Shuck does not diagnose, treat, or prescribe medications.